MIDIRS Informed Choice provides you with an objective appraisal of the best available scientific evidence relating to 21 titles about pregnancy, childbirth and postpartum. The range of Informed Choice topics include those specified in the Clinical Negligence Scheme for Trusts (CNST) Maternity Standards
Parity of provision encourages partnership in information giving between women and their maternity health care professional. The professionals’ versions are fully referenced and designed as the basis for best practice, to open up and guide discussion, and as an aid to clinical decision-making. The women’s versions are factual and presented in an easy-to-read format to help expectant mothers understand their choices, consider their options, and be supported in making informed decisions.
The MIDIRS Informed Choice leaflets and booklets for both professionals and women are available to order in Adobe Acrobat PDF format from the MIDIRS Shop
Informed Choice Leaflets
for Health Professionals and expectant mothers
Informed Choice provides objective summaries of the best available evidence on discrete topics relating to pregnancy, childbirth and postpartum. The government Information Strategy for the Modern NHS stipulates that information received by service users ‘whether directly from professionals or other sources – should be reliable’. Informed Choice provides maternity professionals with accurate information to achieve this and encourages partnership working with childbearing women throughout the decision-making process.
The Leaflets
When first launched in 1996, the Informed Choice leaflets were hailed as a groundbreaking innovation, providing for the first time, objective appraisals of the best available scientific evidence. The leaflets examine key decisions facing expectant mothers during pregnancy, childbirth and postpartum, and are designed to assist them in making informed choices. 21 leaflets for women link to corresponding peer-reviewed publications for professionals; the information is evidence-based and has been rigorously cross-referenced to inform clinical decision-making.
Who are MIDIRS
MIDIRS (Midwives Information and Resource Service) is an educational charity (Reg No. 295346) and Company limited by guarantee (Reg No 2058212).
Our mission is:'To be the leading international information resource relating to childbirth and infancy, disseminating this information as widely as possible to assist in the improvement of maternity care' We aim to fulfil this mission by providing a range of services, all of which are featured on this site. If you have any questions, please phone or e-mail us and we will be pleased to help. Please use the links at the top of the page.
Regularly Reviewed
The leaflets are reviewed on a biennial basis and the methodology for the systematic review and critical appraisal of the literature is approved by the ‘Centre for Reviews and Dissemination’ (CRD), York University.
The addition of six brand new titles means that Informed Choice now covers all the topics specified in the Clinical Negligence Scheme for Trusts (CNST) Maternity Standards.
In April 2004, the women’s leaflets were awarded the Centre for Health Information Quality (CHIQ) Trianglemark Award. Informed Choice is supported by the Royal College of Midwives (RCM) and The National Childbirth Trust (NCT).
Access
Informed Choice utilizes the latest advances in information technology to make this unique facility easily accessible. Health professionals can choose to access all 21 titles as printed versions, online, or on a CD ROM. The information contained in the women’s leaflets can also be delivered electronically by e-mail. Midirs Shop
The Packs
The Informed Choice leaflets are available for bulk purchase by NHS Trusts and other service providers and organizations, and are also available in a range of packages, which can be downloaded in PDF format or can be ordered for postal delivery. Midirs Shop
• www.infochoice.org
MIDIRS Informed Choice Leaflets for Health Professionals
The comprehensive set of Informed Choice leaflets examines key decisions facing expectant mothers during pregnancy and is designed to assist them in making informed choices. Leaflets for women link to corresponding publications for professionals, aiming to provide midwives with sound evidence upon which to base their practice.
1. Support in labour
One-to-one constant support throughout labour has been shown to provide a woman not only with emotional support, so that she is happier and more likely to be relaxed, but also with a strong positive effect on the physiology and outcomes of labour. Research over the past 25 years has shown that the constant presence of a supportive birth companion is one of the most effective forms of care that women can receive during childbirth.
2. Fetal heart rate monitoring in labour
A major part of midwifery care in labour is to observe and record the fetal heart rate to help identify the hypoxic fetus. The techniques range from use of a Pinard stethoscope to complex electronic devices.While it is reasonable to assume that some form of fetal heart rate monitoring during labour has a beneficial effect on fetal outcome, the relative advantages and disadvantages of the various methods will be explored in this leaflet.
3. Routine ultrasound scanning in the first half of pregnancy
Most women in the UK enter pregnancy expecting to receive at least one ultrasound scan and welcome this opportunity to see their baby.They do not generally view it as threatening or, indeed, as a test. It is in this context that health professionals need to help women decide whether or not to have a scan in the absence of clinical indications. Scanning should have the same status as other screening tests, ie women should give informed consent to its use.
4. Alcohol and pregnancy
While there is general agreement that women should not drink excessively during pregnancy, debate has continued over whether there is a safe limit and, if so, at what level it should be set. Women have a right to clear, accurate information on which to make choices about their alcohol consumption. Midwives may also need support where they have concerns about individual women who may be drinking to excess.
5. Positions in labour and delivery
Interest in maternal position during labour is not new, but only recently has there been any research to explore the optimum position for the mother and fetus during labour.
6. The use of epidural analgesia for women in labour
The degree to which individuals can tolerate pain varies considerably and is affected by a number of diverse physiological and psychological factors. This leaflet is about the use of epidural analgesia, a method of blocking the painful stimuli from the contracting uterus enabling a labouring woman to be pain-free.
7. Breastfeeding or bottle feeding
The Informed Choice philosophy is based on the best available evidence and this leaflet is written in a context that is supportive of babies receiving breast milk wherever this is possible.
8. Antenatal screening for congenital abnormalities: helping women to choose
Although the great majority of babies have no disabilities, around 2% have major congenital abnormalities at birth. Only some of these abnormalities can be identified in pregnancy. Antenatal screening for congenital abnormalities is a major component of routine antenatal care, and screening tests for Down's syndrome and neural tube defects (NTDs) are now offered to the majority of pregnant women in the UK.
9. Breech presentation - options for care
The incidence of singleton breech presentation is about 20% at 28 weeks but most of these babies will turn spontaneously before delivery. By term, the incidence has fallen to 3-4%.The occurrence of breech presentation at term appears to be rising, in association with low birth order and high maternal age. In the United Kingdom (UK), as in many other countries in Northern Europe and in North America, caesarean section has recently become the most common mode of delivery for babies presenting by the breech.
10. Place of birth
At the beginning of the 21st century just over 2% of births in England and Wales and well under 1% of those in Scotland and Northern Ireland took place at home. This results from the widespread belief that birth in hospital is safer and that the decline in perinatal mortality seen from the 1960s to the 1980s was due, at least in part, to the increase in the proportion of hospital births.
11. The use of water during childbirth
Since the early 1980s use of immersion in water during labour and birth has been increasingly promoted to enable women to relax, help them cope with pain, and maximise their feelings of control and satisfaction. In 1992 the House of Commons Health Committee recommended all hospitals provide the option of a birthing pool where practicable. Currently few women give birth in water but the option of immersion or showering during the first stage of labour is commonly available.
12. Prolonged pregnancy
Much emphasis is placed on calculating a woman's estimated date of delivery (EDD) early in pregnancy. The EDD hassocial significance in enabling the woman and her partner to prepare for the birth of the baby.
13. Diet and nutrition during pregnancy
Advice to pregnant women on diet and nutrition has changed considerably over the years. In the past, dietary concerns often focused on maternal energy intake and maternal weight gain.
14. Non-epidural strategies for pain relief during labour
Pain relief in labour is strongly associated with women's feelings of control and their knowledge of the likely events that surround the birth experience.
15. Health and care after childbirth
Following childbirth, many women are left with health problems long after the initial six week period classifiedby health care professionals as the puerperium.The high prevalence and persistence of postpartum morbidity has been shown in a number of studies, but it is likely that this is also under-reported by women and poorly identified by health professionals.
16. Mode of delivery and events around the second stage of labour
It is becoming increasingly common for women, midwives and others involved around the time of labour to speak or write about birth, and for those involved in managing labour or intervening to refer to this as a 'delivery'.This is a subtle point, but it perhaps underpins the whole ethos of whether or not labour, and its outcome, is truly within the control of the woman, or of others.
17. Caesarean Section and VBAC (Vaginal birth afterccaesarean)
Women are over four times more likely to have a caesarean birth now than they were thirty years ago. In 1973 the estimated caesarean rate for England and Wales was 5.3 per cent and latest data show a rate for Britain in 2001/2 of 22 per cent.
18. Vitamin K - the debate and the evidence
As such, this leaflet should be seen as a framework for health care professionals to help parents in their understanding of this complex area so that they can make choices about their baby's health based on the best information currently available.
19. Prophylactic anti-D for Rhesus negative women
Within the general population, 16% of people are Rhesus negative. In the context of general health, being Rhesus negative is of most concern where the need for a blood transfusion occurs. However, where women of childbearing age are Rhesus negative this is important as it can have an effect on the outcome of pregnancy.
20. Postnatal depression - symptoms and treatment
The transition to parenthood is a time when familiar patterns of lifestyle can become disrupted by the arrival of a new baby. For women in particular, the fundamental changes and responsibilities that motherhood brings have the potential to be detrimental to their emotional and psychological wellbeing.
21. Sickle cell and thalassaemia disorders - screening offered to mothers and babies
Antenatal and newborn screening for haemoglobinopathies in the United Kingdom has historically been provided on an ad hoc basis with uncoordinated screening in pregnancy and delayed identification of affected infants.
Informed Choice Methodology
‘The provision of reliable information is essential for women and their partners if they areto make decisions that are right for them’
(MIDIRS 2005)
1. Identification of topics
MIDIRS Informed Choice (IC) titles reflect:
• CNST Risk Management Standards for Maternity Services compliance
• Current issues
• Health policy
• Contemporary practice
• Health professionals’ daily information requirements (i.e. Information development is practitioner-led)
MIDIRS Comment:
The guiding principle is that the research evidence is available as the basis for the development of the IC content. MIDIRS is not able to develop information on a topic that remains inconclusive because of insufficient research evidence.
2. Evidence-based research
MIDIRS searches the following data sources:
• The MIDIRS database
• The Cochrane Library
• The database of Abstracts of Reviews and Effects (DARE)
• MEDLINE
• CINAHL
• EMBASE
• TRIP
• ASSIA
• Clinical Evidence Bulletin
• National Research Register
• RCOG Clinical Guidelines
• British Nursing Index
• PsycINFO
MIDIRS Comment:
If particular sources are not used, MIDIRS will indicate why. The research abstracts identified for a particular topic are then passed to the reviewer for their consideration. All research is clearly referenced in Informed Choice leaflets.
3. Development process
• MIDIRS undertakes an extensive search of the published literature (see above) which is systematically reviewed and critically appraised with key papers being identified
• Reviewers’ guidelines for the systematic review and critical appraisal have been developed by MIDIRS in collaboration with the Centre for Reviews and Dissemination (CRD), York University
• These papers are considered individually by a skilled reviewer for information about the conduct of the research, its generalisability, reliability, and overall authority as a piece of evidence
• The critiqued information is then pooled together – either as a systematic review for experimental work, or for agreement on key themes for qualitative studies
• This process results in the overall direction of what would appear to be the evidence in support of best practice
MIDIRS Comment:
Once the framework for the evidence is available, expert opinion, which is different from expert academic review, is included in the process. Each reviewer will identify relevant research papers and copies of the full text articles are sent to them. The reviewer pulls
all the information together, to include key areas where there are practice/clinical points that might cause conflict with the evidence or where there is no evidence.
In addition to the above, MIDIRS reviewers are mindful of the levels of the research included in the review ie The Hierarchy of Evidence, where systematic review and critical appraisal and randomised controlled trials (RCTs) are seen as the ‘gold standard’, and ‘expert opinion’ is viewed as being the least scientifically robust method for the appraisal of the evidence.
5. Standard template
MIDIRS IC has a unique style that has remained virtually unchanged over the past nine years, with each leaflet clearly stating the following:
• What the research evidence says
• What we know
• What we don’t know
• Areas where further research is required
• Implications for practice
MIDIRS Comment
MIDIRS also respects that other forms of information are available and there is a need to consider the role of anecdote, observation and experience which can be obtained from reading the grey literature and which offer a different perspective to many of the
questions that arise in clinical practice. However, this information is still viewed as being inferior to evidence obtained from scientific and experimental studies, which continue to struggle for recognition as part of the evidence-based process for information needs.
Where it is appropriate the IC leaflets recognise this alternative ‘evidence’ and acknowledges that certain aspects of the evidence base remain inconclusive or are unavailable and, for ethical reasons, are likely to remain so.
6. Editorial review
MIDIRS applies a rigorous information and editorial review process to the development of each of the IC titles:
• Draft 1 – Information and editorial review (professional and copy editing)References cited are checked to ensure that they reflect the information contained in each IC title, and to ensure the text is woman-centred and userfriendly (both professionals’ and women’s versions). Each reference is individually checked and each draft is proof read for typographical errors
• 1st Draft sent for external peer review Comments from this process are incorporated into a second draft
• 2nd Draft is returned to the reviewer for their consideration and approval. Once this has been given the drafts are forwarded to the MIDIRS Graphic Designer and the finished products begin to take shape MIDIRS Comments The drafts of the professionals’ leaflets are used as the basis for developing the women’s versions. The content of the women’s versions are more factual in nature and this is reflected in the language used, although the correct obstetric and midwifery terminology are always given. The editorial process involved is every bit as meticulous, with the emphasis being on conveying clearly and concisely, relevant (and sometimes very complex) woman-focused information. The text is supported with photographs and images and additional information and resources are also supplied, enabling childbearing women to seek out further information and advice from specialised organisations and support groups.
7. Parity of information
MIDIRS IC provides two leaflets for each topic, one for childbearing/pregnant women and one for health professionals. The professionals’ leaflets are fully referenced, providing a firm basis for discussion and best practice. The women’s versions provides the facts to help women make decisions that are right for them during their pregnancy and with the option of accessing the professionals’ versions should they prefer more detailed information.
8. Biennial update
MIDIRS Commissions the review (updating) of all its IC titles on a biennial basis to ensure that each one reflects the most up-to-date research evidence and practice development, to form the basis for best practice and shared decision-making in maternity care provision.
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